Application For Certificate Of Self Insurance (Page 3 of 6) in pdf

Application For Certificate Of Self Insurance Page 3

STATE OF ALASKA

DIVISION OF WORKERS COMPENSATION

P.O. Box 115512

Juneau, AK 99811-5512

APPLICATION FOR CERTIFICATE OF SELF-INSURANCE

All questions must be answered, and requested material submitted. If not applicable, use symbol N/A. Workers

compensation insurance must be maintained until self insurance authorization is effective.

1. Legal name of the Alaskan employer

2. Mailing address of the Alaskan employer

3. Name and address of the individual responsible for the employer’s self-insured program

Name

Title

Mailing address

Telephone number

Fax number

Email address

4. Type of business structure of the Alaskan employer (Check One)

Corporation

Partnership

Joint Venture

Limited Partnership

Limited Liability Company

Limited Liability Partnership

Municipality or Public Authority

Other (explain below)

5. If the Alaskan employer is a wholly owned or majority owned subsidiary, provide the legal name,

mailing address, and percent of ownership of the parent or controlling company.

6. If the Alaskan employer is a joint venture, provide the legal names, mailing address, and ownership

percentage of each person having an ownership interest in the venture (attach additional pages if

necessary).

7. Provide the North American Industry Classification System (NAICS) code number that the Alaskan

employer conducts its affairs under and a brief description of its business activities

NAICS Code

Description of business Activities in Alaska

8. Alaska employer's federal employer identification number

9. Provide the Alaska employer's Alaska State Business License number and, if applicable, the Alaska

Department of Commerce ID number

Business License Number

Commerce ID Number

07-6129 (rev 8/2/10)

Application For Certificate Of Self Insurance Page 3